Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Friday, June 18, 2010

The Day After

It's rainy outside.

The dog's hungry and needs to be let out.

I still need to shave and shower.

And yes, I'm going to work today.

They tell me the doctor Medicare cuts went through. You mean the AMA, with all their sound and fury signifying nothing, failed to influence our Congressional leadership?

Gee, who knew?

Folks, this was the plan. The cuts were supposed to go through. So look at it on the bright side. Our government just saved $250 billion!

And quietly, practices will downsize their nicest employees or close all together. Many others will speed up their flight to be bought by big hospital systems - but these hospital systems will be more selective when deciding who they admit to their ranks. Inner city hospitals, struggling for survival, will look to the government for more subsidies to meet their demands for survival. Government will comply to protect themselves. Big hospitals and health systems with lots of doctor-employees will point to the decreased revenue by their doctors, tighten their belts a bit more by maintaining their months-long hiring freezes indefinitely, and fail to give those productivity bonuses to their workers as their construction contracts for their additions continue to get paid as they get ready for the "Big Wave."

In business, nothing changes quickly. Especially big, money-hungry, bureaucratic machines. But the paranoia will grow amongst the administrative and medical supplier ranks as senior leadership looks to cut back. You see, doctors are just the first.

And then there's the patients. If you're in a big town, you won't notice the difference. That's because in the operating rooms, there will still be one nurse where there had been two. In the ICU's, your nurse will visit you a bit less, but thanks to electronics, she'll still be watching or listening for you. You might notice it's harder to understand the foreign accent of your doctor, but he or she will be pleasant. At least until the next doctor arrives on the night shift.

But for the rural patients. Best of luck. Hope you've got frequent flier miles or low mileage on your car. You're going to need it. I have no doubt that you'll be able to get a telemedicine doctor to see you, provided you have more than a dial-up connection and a new computer with a videocam. What, you can't afford one? Better ask the government for a computer, then, okay? And while you're on the phone, ask them how possible acute appendicitis will be handled, will you?

Fortunately, if you're below 65, you'll see the effects a bit later. But if you're over 65, better tap into your savings a bit, so you can pay to have a doctor.

Hello Wes,I'm one of those community physicians who won't have much left after overhead with the medicare cuts. If the cuts go through, I may have to bail out as a Medicare 'provider' and I'm still in disbelief. I have a big skin cancer practice, my patients and I are aging together and I can't imagine practicing off Medicare. My profit margin simply doesn't compute with the cuts and I'll have to face that if and when the time comes-which may be soon. What am I to do? Cynthia Bailey MDhttp://www.otbskincare.com/blog/

Doctors are among the most highly compensated professionals, receiving far more than comparable european docs. They are all levered up to run their spiffy lifesyles -- and certainly have no professional alternative that pays more than clinical medicine. Far more highly qualified people apply to med school than can be accepted. Most docs can't survive w/ medicare patients. As taxpayers and patients, this is an easy decision -- pay 'em less. They really are stuck. They'll likely work even harder to make up the lost income -- most docs in my acquaintance have debt out the eyeballs. Sadly, congress will almost certainly roll over and pass another "doc fix" soon.

Well, the AMA supported the Heath Care bill with the cuts because that was one of the "tricks" to make the numbers work. Everyone assumed that Congress would put the money back in once the bill passed. Oops. Funny thing is, I don't remember either the AMA, hospitals or AARP complaining about the cuts or lobbying against the bill. Reap what you sow.

Don't count on the doc fix anytime soon. With the "don't let a crisis go to waste" mentality in DC, expect politicians on both sides to exploit the issue. The Feds have slammed the door on the medical profession. Physicians will be caught in the middle of an intense political battle.

Ignatz, certainly some docs are stuck as you say, particularly recent grads. Physicians my age (low 50s) may have a lot more choices in how they order their professional life. American specialists may make more than Europeans, but primary care docs are about the same now. We will see, but I don't think the overall response will be as static as you think.

From my point of view as a patient, doctors have long deserved to be squeezed. I am a non-believer in insurance, but I'll be damned if I can find a doctor who posts his prices by CPT code, so I can shop around.

I can't wait until Walmart, Target, Sears, Home Depot or Lowes runs clinics, pharmacies and hospitals. They know how to publish their ever-falling prices on the Web and they don't take 3rd-party payers for their non-medical products.

I read of doctors in Miami and South Carolina who have stopped accepting all insurance and medicare/medicaid patients. Trouble is, there are none to be found around Austin, Texas.

Ah yes - a few remind us that wealth envy is still the standard in these United States. Yes - many Doctors with specialties are very well compensated. But consider the level of their education and continual schooling to remain at the top of their professional I hardly think the compensation is excessive. Sorry, jimbino. I have been with my cardiologist since my first heart attack in 1981. HE SAVED MY LIFE! What price tag can be affixed to that? I am now one of his oldest patients (in time - not age) and don't have a clue what I'll do if he gives up his practice and concentrates on his second position as Director of medicine at a major hospital here in NY. His practice has not accepted my former health insurance plan for at least 12 years - yet he continues to charge me only the copay from that plan. Doesn't have to, but he's a dedicated professional who cares about his now mostly aged patients. Put a price tag on that one, jimbino. He takes one vacation a year with his family and drives what looks like a 3 year old mid-range car. His malpractice insurance - though according to his writeup in Best Doctors in America says he has never, ever, been sued - would wipe out my social security disability AND pension.

The implications of ObamaCare[sic] on the lives of Americans is too horrifying to consider. Doc Wes is too right.

The air is leaking out of the Medicare balloon. The Medicaid balloon has already crashed. I'll be 65 in 3 years & I'm not signing up for Medicare. My insurance co wants me to sign up so Medicaere will be primary. The insurance will waive deductibles & copayment if I do. But I prefer to pay more & actually have a doctor when I need one.

Anyone who thinks doctors are overpaid has no idea what it takes to do what they do, or what their job requires once they get there. There is no other career choice that matches the level of requirements and personal sacrifice - NOT one.

How many CEO's miss Christmas mornings with their kids because they are rounding on ICU patients? How many lawyers must leave their spouse at 2 am to perform a high risk, life saving angioplasty - all the while being clocked by the hospital they for? How many politicians are sued for malpractice that causes the death of another American? Political malpractice is an entirely new subject, and one I wish we were talking about.

There is a small percentage of a population intelligent enough to get into medical school. In that group, there is another small percentage willing to make the personal sacrifices of intense studying, coursework, and length of years it takes to finish. Then, again, in that small group there is an even smaller group of people up to the task of blood, guts, and human pain/suffering.

So, let's take away their salaries and see how many human beings we then have left willing to make the huge sacrifices.

I'm only 41 years old, and I have two year old triplets. I am more afraid of our future and not having doctors to care for us than I am of our looming national debt.

If every doctor left medicine tomorrow - I would not blame them, and I would understand why.

Lets get down to brass tacks. Specialists in this country make more than anywhere else in the world. Average starting salaries for interventional cardiologists start around 300 K. Compared to cognitive specialites like infectious disease, rheumatology, and endocrinology, you guys make alot more even though these specialites require extra years of training as well (specialists always use their extra years of training to explain income disparities but never reconcile those specialties that require equal amounts of extra training, but don't get much financial return for that investment). How come specialties that poke holes in patients make so much more than those that don't?

While the actions of congress in respect to physicians salaries is despicable, I don't get the impression that cardiologists are suffering in the same way many people are throughout this country. And the percntage drops to primary care are more devastating than those on highly compensated specialists!

One thing I can tell you is that as more and more physicians become employees of large health care systems, positions in desireable areas of the country will become very competitive and will depress salaries as the administrators realize they can get a cardiologist at a dime a dozen. Rural areas, as you point out, will suffer, but good luck trying to make a decent buck in a major metropolitan area. It's all the result of our profession handing over control to administrative professionals who have, and will, look at us as just another human resource commodity.

Brass tacks: innovation in medicine has largely been the pervue of the US and its industries. I would expect doctors in the US to make more than other countries, especially diven the additional costs we incur compared to them. $300,000 for medical school these days? Malpractice premiums?

I do not disagree with you the argument that subspecialties should be equally compensated whether invasive or not. But for those who undergo additional training and certification in their fields, they should also be compensated more than those who elect not to purse this training.

About the only reasonable way to pay people is for their time - just like other professions do. Here's my proposal: you make $100/hr once you complete sucessfully medical school and enter the workplace, $200/hour for your first medical board, $300/hour as for your second medical board, and $400 for your third, if and only if you could prove you were actively participating in each specialty and continued to maintain CME/credentials for the same. Note that these rates are cheaper than other similarly-regarded professions.

Think what this would do.

No more ICD-9, ICD-10, or "ICD- 50,000" codes. No more "gee, I wonder how much this will cost." People know what they're getting up front while removing the hoards of middlemen.

Problem solved.

Except for the problem dealing with the unemployment of coders, billers, recovery audic contractors, radiology percertification specialty companies, and on and on and on.

Billions saved in the blink of an eye.

Simple.

Who would have thought a doctor could come up with something?

Bottom line, Keith: no one wants to listen because doctors are not the ones fleecing the system.

Take heart (at least half a heart). The temporary fix will be signed on Monday. Congress takes Friday off. What's of more interest are your comments about the lack of broadband in rural areas. T'was ever such! Read up on the TVA and electrification in Texas (under the Democrats which gave birth to KBR which morphed to Halliburton). Libertarians may want to be "left alone" but they better not wait for corporate companies to extend broadband to less populated areas. They have to be dragged by the (horrors!) government and the inevitable lucrative government contracts. Even John Galt can't bring broadband to rural America. Yes, it will cost us all to get the coverage, just as it cost us all to build the highways - under that well known socialist: Eisenhower! Just as docs want to be compensated for their invaluable care, so do the guys who build the highways of either concrete of fibre optics.

I think we should limit what attorneys are allowed to charge.Why should it cost so much just todo a simple will or family trust?Especially when legal secretariesdo most of the work! I also believe that lawyers should not beallowed to run for public office;they have wrecked our judicial system with their legal shenanigans. Anonymous R.N.

Every so often you come up with a good idea. I am not sure that the translation is that good however unless that compensation extends to on call time as well.

What about say neurosurgery where you may spend 7-8 years in post medical school training to get to your second board? So neurosurgeons would get 200/hour?

I think a better measure would be those additional years of training with some less than linear ramp up of payment the farther out you go. Maybe we need to consider how later years of post graduate training get compensated and having salaries that match the level of training rather than the current system of menial wages until you complete your residency.

I also see one big problem with this idea. How do you keep docs from performing menial tasks that could be performed by mid level personel? If you are paying an hourly wage, how do you control the type of work that is performed? Could I suddenly fire my receptionist and spend my day answering my own phone for 200/hour? Or do my own filing in the office? This could seemingly eliminate nurse practitioners and all their activity unless you intend to reimburse them at the same rates (do they get the 100/hour rate comparable to a medical school grad or what?) since their tasks could now be performed and reimbursed by a doctor at a higher rate. And what if the quadrauple boarded physician now decides he would rather do primary care (I grant you an unlikely senario, but instance where a surgeon becomes physically disabled but still mentally competent have occurred where they then enter cognitive fields)? Does he now get 400/hour for doing the same task that the single boarded primary care doc gets?

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.